ATI RN
ATI RN Fundamentals 2023 Questions
Extract:
A nurse is caring for a client.
Vital Signs
0800:
Temperature 37.6° C (99.7 F) Blood pressure 108/56 mm Hg Heart rate 66/min Respiratory rate 18/min
Pulse oximetry 97% on room air 0830:
Temperature 37.5° C (99.5° F) Blood pressure 88/56 mm Hg Heart rate 104/min Respiratory rate 24/min
Pulse oximetry 93% on room air Nurses' Notes
0800:
Antibiotic administered as prescribed.
Bilateral breath sounds clear and present throughout. 0830
Client reports itching over the chest area and has urticaria over chest and trunk.
Client states tongue feels swollen
Question 1 of 5
Bilateral breath sounds with scattered wheezing upon auscultation, Select the 4 findings that require immediate follow-up.
Correct Answer: B,D,E,F
Rationale: The correct answer is B, D, E, and F. Monitoring blood pressure (
B) is crucial to assess for potential respiratory distress. Urticaria (
D) indicates a possible allergic reaction requiring immediate attention. Swollen tongue (E) can be a sign of angioedema, a severe allergic reaction affecting the airway. Bilateral breath sounds with wheezing (F) suggest respiratory compromise requiring prompt intervention. Heart rate (
A) and temperature (
C) are important but not as urgent in this scenario.
Extract:
Question 2 of 5
A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse, 'I want to die now that my partner is gone.' Which of the following responses should the nurse make?
Correct Answer: B
Rationale:
Correct Answer: B: Have you thought about harming yourself?
Rationale: This response is crucial as it directly addresses the client's statement about wanting to die. It shows the nurse's concern for the client's safety and well-being. By asking about potential self-harm, the nurse can assess the client's level of risk and take appropriate actions to ensure their safety.
Incorrect
Choices:
A: You should discuss these feelings with your provider.
- This response delays addressing the immediate risk of self-harm and may not provide the necessary support in a critical moment.
C: Why did you stop taking your medication?
- While important, this question is not as urgent as assessing the client's immediate safety regarding self-harm.
D: Tell me more about your partner.
- While understanding the client's emotions is important, this response does not address the immediate risk of self-harm and may not prioritize the client's safety.
Question 3 of 5
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?
Correct Answer: C
Rationale:
Correct Answer: C. Prepare the client for a central venous line.
Rationale: PN with high osmolarity and high glucose concentration can cause vein irritation and damage peripheral veins.
Therefore, the use of a central venous line is appropriate to minimize the risk of complications like phlebitis and thrombophlebitis.
Incorrect
Choices:
A: Obtaining a random blood glucose daily is important for monitoring blood glucose levels in clients receiving PN, but it does not address the need for a central venous line.
B: Changing the PN infusion bag every 48 hours is a standard practice to prevent contamination but does not address the need for a central venous line.
D: Administering the PN and fat emulsion separately is not necessary as they are often combined in one infusion for convenience and efficiency.
Question 4 of 5
A nurse is caring for an adolescent client who has full-thickness burns on their leg. The client expresses concern about their future. Which of the following is a therapeutic response by the nurse?
Correct Answer: C
Rationale: The correct answer is C because it acknowledges the client's feelings and shows empathy. By reflecting the client's concern about the future, the nurse validates their emotions and opens up the opportunity for further discussion and support. Option A minimizes the client's concerns, B dismisses their feelings, and D is confrontational and may make the client feel judged.
Therefore, choice C is the most therapeutic response as it promotes a trusting nurse-client relationship.
Question 5 of 5
A nurse manager overhears a nurse telling a client, 'I will administer your medication by injection if you don't swallow your pills.' The nurse manager should identify that the nurse is committing which of the following torts?
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional threat of harmful or offensive contact with an individual that causes reasonable apprehension of imminent contact. In this scenario, the nurse's statement of administering medication by injection if pills are not swallowed constitutes a threat of harm, leading to the client's reasonable fear of imminent bodily harm. Defamation (
B) involves false statements that harm a person's reputation, Battery (
C) is the intentional harmful or offensive contact without consent, and Invasion of privacy (
D) involves intruding on an individual's private affairs. In this case, Assault best fits the situation described.